Provider Demographics
NPI:1366695405
Name:MCCOLLOM, THERESA MARIE (PTA)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:MARIE
Last Name:MCCOLLOM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17800 KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-2029
Mailing Address - Country:US
Mailing Address - Phone:708-213-3825
Mailing Address - Fax:
Practice Address - Street 1:17800 KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-2029
Practice Address - Country:US
Practice Address - Phone:708-213-3829
Practice Address - Fax:708-422-1812
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2022-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005041225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant